Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Holiday Hill Inc during CMS and state inspections, most recent first.
The facility failed to properly store, prepare, and serve food according to safety standards, with pureed foods not reheated to 165°F and incomplete temperature logs for meals. Staff acknowledged these oversights, attributing them to forgetfulness and turnover, despite expectations for adherence to protocols.
The facility failed to implement comprehensive care plans for three residents, neglecting to address critical needs such as an indwelling urinary catheter, continuous glucose monitoring, weight loss, fall prevention, and hospice services. Despite having physician orders, these needs were not reflected in the care plans, potentially impacting resident care. The DON and MDS Coordinator acknowledged the omissions, with the MDS Coordinator responsible for creating care plans and the DON for their review.
The facility failed to conduct regular inspections of bed frames and bed rails, posing potential entrapment risks for two residents who used bed rails as enablers. Despite facility policy requiring routine inspections, there was no evidence of such inspections being conducted. Interviews revealed that the maintenance director only inspected bed rails when informed of issues, and no documentation of inspections or repairs was maintained.
The facility failed to attempt alternative measures and assess entrapment risks before installing bed rails for two residents with cognitive and mobility impairments. Observations confirmed the use of bed rails without documented assessments, and staff interviews revealed uncertainty about responsibility for these assessments, contrary to facility policy.
A facility failed to ensure proper wound care documentation for a resident with severe cognitive impairment and multiple medical conditions. Nurses did not initial and date the wound dressings as required by the care plan and facility policy. An RN admitted to performing the wound care but forgot to mark the dressing. Staff interviews emphasized the importance of this practice for continuity of care.
Failure to Maintain Food Safety Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the storage, preparation, distribution, and serving of food. During an observation, it was noted that pureed beef taco meat and charro bean soup were not reheated to the required temperature of 165 degrees Fahrenheit for 15 seconds after being pureed with cold milk. Instead, the food was placed directly into the steam table, resulting in temperatures of 110 degrees Fahrenheit for the beans and 95 degrees Fahrenheit for the meat, which were below the safe holding temperature of 140 degrees Fahrenheit. This oversight was acknowledged by the staff member responsible, who then attempted to correct the temperatures by placing the food in the oven. Additionally, the facility failed to maintain accurate temperature logs for meal services. A review of the temperature logs revealed numerous instances where temperatures were not recorded for various meals, including breakfast, lunch, and supper, over several months. This lack of documentation was acknowledged by the Dietary Manager (DM), who attributed it to staff turnover and forgetfulness. The DM and the Dietitian both emphasized the importance of following recipes and maintaining temperature logs to ensure food safety, yet the logs remained incomplete. Interviews with the facility's administration and dietary staff highlighted a lack of adherence to established food safety protocols. The Administrator (ADMN) and DM both expressed expectations that food should be reheated to 165 degrees Fahrenheit as per recipes and that temperature logs should be completed for every meal. Despite these expectations, the facility's practices did not align with these standards, as evidenced by the incomplete logs and improper reheating of food. The failure to follow these protocols could potentially place residents at risk for foodborne illnesses, although no specific negative effects on residents were reported.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which included measurable objectives and time frames to meet their medical and nursing needs. Resident #1, a male with intact cognition, had no care plan addressing his indwelling urinary catheter, continuous blood glucose monitoring device, or significant weight loss. Despite having physician orders for these conditions, the care plan was not updated to reflect these needs, potentially impacting the resident's care. Resident #32, a male with severe cognitive impairment, had a physician's order for a fall mat due to his risk of falls. However, the care plan did not include the use of a fall mat as an intervention, and during an observation, no fall mat was present in the resident's room. This oversight occurred despite the resident having experienced multiple falls, including one with injury, since admission. Resident #57, a female with severe cognitive impairment receiving hospice care, did not have hospice services addressed in her comprehensive care plan. The facility's Director of Nursing (DON) and MDS Coordinator acknowledged the omissions in the care plans and stated that the MDS Coordinator was responsible for creating them, with the DON ultimately responsible for their review and revision. The facility's policy requires care plans to be reviewed and updated when there is a significant change in the resident's condition.
Failure to Conduct Regular Bed Rail Inspections
Penalty
Summary
The facility failed to conduct regular inspections of bed frames and bed rails, which could lead to potential entrapment risks for residents. This deficiency was identified during observations, interviews, and record reviews for two residents who had bed rails as enablers. The facility's policy required routine inspections to ensure no gaps in the bed system that could entrap a resident's head or body, but there was no evidence of such inspections being conducted. Resident #4, a female with severe cognitive impairment and reduced mobility, had half rails on both sides of her bed. Her care plan and physician orders allowed for these rails as enablers. However, there was no documentation of regular inspections of her bed rails. Similarly, Resident #9, who had moderate cognitive impairment and used a bed rail for mobility, also had no evidence of regular inspections of her bed rails. Both residents were observed with bed rails in the up position, but the facility did not maintain records of inspections or repairs. Interviews with the maintenance director and administrator revealed a lack of routine assessments for bed rail safety. The maintenance director only inspected bed rails when informed of issues by staff, and there was no log of these inspections. The administrator was unaware of who monitored the inspections and stated that the maintenance director would address issues brought to his attention. Despite the facility's policy requiring routine inspections and documentation, no such records were available, indicating a failure to adhere to established safety protocols.
Failure to Assess Bed Rail Alternatives and Entrapment Risks
Penalty
Summary
The facility failed to attempt alternative measures before installing bed rails and did not assess the risk of entrapment for two residents. Resident #4, a female with severe cognitive impairment and mobility issues, had bed rails installed without documented attempts to use alternatives or an assessment for entrapment risks. Observations confirmed the presence of half rails in the up position on both sides of her bed. Similarly, Resident #9, a female with moderate cognitive impairment and mobility challenges, also had bed rails installed without evidence of alternative measures or entrapment risk assessment. Observations showed a half rail in the up position on one side of her bed, which she used for mobility. Interviews with staff revealed a lack of clarity on who was responsible for conducting these assessments, and it was confirmed that no assessments had been performed for these residents. The facility's policy requires attempts to use alternatives and a comprehensive assessment before installing bed rails, which was not adhered to in these cases. The policy outlines specific criteria for assessing the risk of entrapment, including medical conditions, mobility, and cognition, none of which were documented for the residents in question.
Failure to Date and Initial Wound Dressings
Penalty
Summary
The facility failed to ensure that wound care was performed in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident. Specifically, the nurses did not initial and date the wound dressings after performing wound care on a resident with severe cognitive impairment and multiple medical conditions, including hemiplegia and hemiparesis following a cerebral infarction. The physician's orders required the resident's left thigh wound to be cleansed, patted dry, and dressed with Xeroform and a super absorbent dressing every Tuesday, Thursday, and Saturday until healed. During an observation, it was noted that the dressing on the resident's thigh was clean but lacked a date and initials. An RN admitted to performing the wound care but forgot to mark the dressing due to not having a marker at the time. Interviews with staff, including an LVN and the DON, highlighted the importance of dating and initialing wound dressings to ensure continuity of care and adherence to the facility's wound care policy, which mandates marking the dressing with initials and date.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Coleman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coleman Healthcare Center | 1.9 mi | — | 11 | 0 |
| Bangs Nursing And Rehabilitation | 20.5 mi | — | 0 | 0 |
| Brownwood Nursing And Rehabilitation | 28.3 mi | — | 11 | 0 |
| Songbird Lodge | 28.3 mi | — | 15 | 0 |
| Oak Ridge Manor | 28.5 mi | — | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.